Recurrent Emergency Department Attendance by a Patient Experiencing Homelessness: A Narrative Review of Inclusion Health Models of Care
DOI:
https://doi.org/10.5281/zenodo.22227885Keywords:
Inclusion Health, Homelessness, Emergency Department Attendance, Housing First, Health InequalityAbstract
A patient who attends the emergency department repeatedly is usually described as a problem for the department. The evidence
suggests the reverse: repeated attendance is what happens when every other door is closed, and it marks a population dying
decades early.
Objectives: To review the published evidence on health outcomes and service use among people experiencing homelessness, and
on the models of care developed in response: what the mortality gap is, how emergency and inpatient use differs from the housed
population, and what the evidence for intervention actually supports.
Material and Methods: Narrative review of systematic reviews, meta-analyses, matched cohort studies, randomised trials of
housing and care interventions, and policy guidance indexed in PubMed and the major public health and general medical
journals. No new patient data were generated; every estimate quoted is one published by the original investigators.
Results: Across 337 studies, all-cause standardised mortality ratios were 11.86 (95% CI 10.42 to 13.30) in women and 7.88 (7.03
to 8.74) in men, and were significantly raised in 91 of 92 extracted datapoints. In a matched English cohort of 16,161 homeless
and 74,780 housed emergency department attendees, admissions ran at 470 against 230 per 1000 patients per year; adjusted rate
ratios were 1.79 for all admissions, 2.08 for emergency admissions and 1.65 for ambulatory care-sensitive admissions. Housing
First reduced emergency department visits (IRR 0.63) and hospitalisations (IRR 0.76), from four trials all judged at high risk of
bias.
Conclusion: The excess use concentrates in conditions that should have been managed elsewhere, which locates the failure
upstream of the emergency department rather than inside it. The interventions with the best evidence supply housing and
continuity rather than clinical novelty, and the quality of that evidence is weaker than the consistency of its direction suggests.
Abbreviations: ACS – Ambulatory Care-Sensitive, ED – Emergency Department, HF – Housing First, IRR – Incidence Rate
Ratio, SMR – Standardised Mortality Ratio, CI – Confidence Interval.
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